Healthcare Provider Details

I. General information

NPI: 1679568703
Provider Name (Legal Business Name): SANDRA BETH GOODMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5245 E FLETCHER AVE SUITE 1
TAMPA FL
33617-1126
US

IV. Provider business mailing address

5245 E FLETCHER AVE SUITE 1
TAMPA FL
33617-1126
US

V. Phone/Fax

Practice location:
  • Phone: 813-914-7304
  • Fax: 813-676-8812
Mailing address:
  • Phone: 813-914-7304
  • Fax: 813-676-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberME79728
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number60592
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number19268
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberD42657
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number51258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: